Difference between revisions of "Cerebral angiogram"
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A '''cerebral angiogram''' (also known as '''cerebral arteriogram''') is a procedure where contrast is injected through an artery and X-Rays are used to visualize the cerebral blood flow. It is performed by neuro-interventional radiology. | |||
== Overview == | == Overview == | ||
=== Indications === | === Indications === | ||
It can be used to further investigate cerebral hemorrhage, AV malformations, cerebral aneurysms, blood flow to tumor, or other abnormal arterial blood flow. | |||
=== Surgical procedure === | === Surgical procedure === | ||
The most common approach is through the femoral artery, though occasionally it can be done through the radial artery (e.g. if patient has history of femoral bypass procedure). Upon access the artery through catheter, contrast is injected with timed X-ray imaging. | |||
=== Type of anesthesia === | |||
This procedure can be done without anesthesia or with MAC anesthesia for most patients who are able to follow commands and lie still, and if the the procedure is purely diagnostic in nature. If a patient is unable to lie still, or will need additional treatment (e.g. embolization, stent placement, etc.), then general anesthesia is used. | |||
== Preoperative management == | == Preoperative management == | ||
| Line 29: | Line 34: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Depending on the abnormality being explored, patients may have baseline neuro deficits which should be known preoperatively | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Patients with aneurysms and history of hypertension should continue antihypertensives to avoid sheer stress | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| Line 54: | Line 59: | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
Coags, BMP (to evaluate kidney function prior to high volume contrast) | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
In general, multiple C arms in different planes are used, so the anesthesia machine and monitors are situated far from patient. Multiple extensions are needed for any lines (PIVs, arterial lines, central lines) and long cables for monitors. | |||
For patients with tight blood pressure control required (e.g. cerebral hemorrhage, aneurysm), prepare multiple antihypertensives (nicardipine infusion, nitroglyceride injection) and vasopressors (norepinephrine infusion, phenylephrine injection). | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
If there is high concern for neurologic deficit, medications that may alter mental status exam postoperatively should be used with caution: e.g. midazolam, scopolamine patch. | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
N/A | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* Standard ASA monitors | |||
* 1-2 PIV | |||
* Arterial line if patient requires strict blood pressure goals (e.g. cerebral hemorrhage) or is otherwise hemodynamically unstable. | |||
* Patients with elevated ICP may present with external ventricular drain (EVD) requiring ICP monitoring and ICP fluid drainage. | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
Standard induction. Slow cardiac induction if indicated for tight blood pressure management. | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Supine | |||
* All lines and monitors must be out of plane with the head and shoulder area to avoid obstructed X-ray imaging. Generally across the chest. | |||
* Consider extensions on PIVs | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* Maintain deep paralysis as imaging of requires breath holding to avoid ventilatory variation. | |||
* If active cerebral hemorrhage | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
Neurologic exam is often obtained upon emergence | |||
== Postoperative management == | == Postoperative management == | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* Generally PACU | |||
* ICU if significant neurological intervention is required (for neuro monitoring) or otherwise hemodynamically unstable (e.g. cerebral hemorrhage) | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
Generally minimal pain management is needed as there is only a small incision for catheter placement. | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
Latest revision as of 14:50, 20 June 2022
Cerebral angiogram
| Anesthesia type |
General vs MAC vs no anesthesia |
|---|---|
| Airway |
ETT vs natural airway |
| Lines and access |
1 PIV |
| Monitors |
Standard |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
Maintain normotension if aneurysm |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 1 |
A cerebral angiogram (also known as cerebral arteriogram) is a procedure where contrast is injected through an artery and X-Rays are used to visualize the cerebral blood flow. It is performed by neuro-interventional radiology.
Overview
Indications
It can be used to further investigate cerebral hemorrhage, AV malformations, cerebral aneurysms, blood flow to tumor, or other abnormal arterial blood flow.
Surgical procedure
The most common approach is through the femoral artery, though occasionally it can be done through the radial artery (e.g. if patient has history of femoral bypass procedure). Upon access the artery through catheter, contrast is injected with timed X-ray imaging.
Type of anesthesia
This procedure can be done without anesthesia or with MAC anesthesia for most patients who are able to follow commands and lie still, and if the the procedure is purely diagnostic in nature. If a patient is unable to lie still, or will need additional treatment (e.g. embolization, stent placement, etc.), then general anesthesia is used.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | Depending on the abnormality being explored, patients may have baseline neuro deficits which should be known preoperatively |
| Cardiovascular | Patients with aneurysms and history of hypertension should continue antihypertensives to avoid sheer stress |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Coags, BMP (to evaluate kidney function prior to high volume contrast)
Operating room setup
In general, multiple C arms in different planes are used, so the anesthesia machine and monitors are situated far from patient. Multiple extensions are needed for any lines (PIVs, arterial lines, central lines) and long cables for monitors.
For patients with tight blood pressure control required (e.g. cerebral hemorrhage, aneurysm), prepare multiple antihypertensives (nicardipine infusion, nitroglyceride injection) and vasopressors (norepinephrine infusion, phenylephrine injection).
Patient preparation and premedication
If there is high concern for neurologic deficit, medications that may alter mental status exam postoperatively should be used with caution: e.g. midazolam, scopolamine patch.
Regional and neuraxial techniques
N/A
Intraoperative management
Monitoring and access
- Standard ASA monitors
- 1-2 PIV
- Arterial line if patient requires strict blood pressure goals (e.g. cerebral hemorrhage) or is otherwise hemodynamically unstable.
- Patients with elevated ICP may present with external ventricular drain (EVD) requiring ICP monitoring and ICP fluid drainage.
Induction and airway management
Standard induction. Slow cardiac induction if indicated for tight blood pressure management.
Positioning
- Supine
- All lines and monitors must be out of plane with the head and shoulder area to avoid obstructed X-ray imaging. Generally across the chest.
- Consider extensions on PIVs
Maintenance and surgical considerations
- Maintain deep paralysis as imaging of requires breath holding to avoid ventilatory variation.
- If active cerebral hemorrhage
Emergence
Neurologic exam is often obtained upon emergence
Postoperative management
Disposition
- Generally PACU
- ICU if significant neurological intervention is required (for neuro monitoring) or otherwise hemodynamically unstable (e.g. cerebral hemorrhage)
Pain management
Generally minimal pain management is needed as there is only a small incision for catheter placement.
Potential complications
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
Top contributors: Tony Wang